Mid‐urethral sling revision for mesh exposure–long‐term outcomes of two surgical techniques from a comparative clinical retrospective cohort study

Surgical Removal of Midurethral Sling in Women Undergoing Surgery for Presumed Mesh-Related Complications: A Systematic Review

OBJECTIVE

To assess whether some, or all, of the mesh needs to be removed when a midurethral sling is removed for complications.

DATA SOURCES

A systematic review and meta-analysis was conducted. MEDLINE, Cochrane, and ClinicalTrials.gov databases from January 1, 1996, through May 1, 2021, were searched for articles that met the eligibility criteria with total, partial, or a combination of anti-incontinence mesh removal.

METHODS OF STUDY SELECTION

All study designs were included (N≥10), and a priori criteria were used for acceptance standards. Studies were extracted for demographics, operative outcomes, and adverse events. Meta-analysis was performed when possible.

TABULATION, INTEGRATION, AND RESULTS

We double-screened 11,887 abstracts; 45 eligible and unique studies were identified. Thirty-five were single-group studies that evaluated partial mesh removal, five were single-group studies that evaluated total mesh removal, and five were studies that compared partial mesh removal with total mesh removal. All of the studies were retrospective in nature; there were no randomized controlled studies. Comparative studies demonstrated that partial mesh removal had lower rates of postoperative stress urinary incontinence (SUI) than total mesh removal (odds ratio 0.46, 95% CI 0.22-0.96). Single-group studies supported lower rates of postoperative SUI with partial mesh removal compared with total mesh removal (19.2% [95% CI 13.5-25.7] vs 48.7% [95% CI 31.2-66.4]). Both methods were similar with respect to associated pain, bladder outlet obstruction, mesh erosion or exposure, and lower urinary tract symptoms. Adverse events were infrequent.

CONCLUSION

Postoperative SUI may be lower with partial mesh removal compared with total mesh removal. Other outcomes were similar regardless of the amount of mesh removed.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO, CRD 42018093099.

Symptomatic improvement after mesh removal: a prospective longitudinal study of women with urogynaecological mesh complications

OBJECTIVE

To compare clinical characteristics and outcomes in patients undergoing excision of polypropylene urogynaecological mesh for pain, mesh exposure or both.

DESIGN

Prospective, longitudinal cohort.

SETTING

Academic tertiary referral centre.

POPULATION

Women undergoing complete vaginal mesh excision for mesh exposure and/or pain.

METHODS

Clinical and patient-reported outcomes assessing pain (visual analog scale, VAS), bother (Pelvic Floor Distress Inventory, PFDI) and functional impact (Pelvic Functional Impact Questionnaire, PFIQ) were collected at baseline, 6, 12 and 24 months after complete mesh excision. Outcomes were compared by mesh type (sling, prolapse [transvaginal or sacrocolpopexy mesh], both) and complication (pain, exposure, both).

MAIN OUTCOME MEASURES

'Much better' or 'Very much better' on Patient Global Impression of Improvement (PGI-I) up to 2 years after removal.

RESULTS

Of 173 women, 48 underwent removal for pain, 27 for exposure and 98 for exposure plus pain. 'Moderate to severe' baseline symptoms were reported by 75%; the most prevalent and severe symptom was dyspareunia. Patients with pain alone were most bothered (PFDI median 234.2, interquartile range 83, P = 0.02) and had the highest functional impact (PFIQ median 181, interquartile range 138, P < 0.001). After excision, only 33.3% of women with pain alone reported 'improved' symptoms (PGI-I), versus 73.9% with exposure, 58.3% with exposure plus pain (P = 0.03) with no differences in PGI-I by mesh type. VAS scores decreased in all groups, but PFDI and PFIQ did not improve in pain patients.

CONCLUSIONS

In women experiencing a pain complication after urogynaecological mesh insertion, mesh removal often does not improve symptoms.

TWEETABLE ABSTRACT

Only 33% of women with pain complications have improved symptoms after urogynaecological mesh removal.

Long-term effectiveness and safety of open Burch colposuspension vs retropubic midurethral sling for stress urinary incontinence-results from a large comparative study

BACKGROUND

There are few adequately powered long-term trials comparing midurethral sling and Burch colposuspension. Recent concerns about synthetic mesh with new stringent clinical and research governance support the need for evidence to facilitate shared decision making.

OBJECTIVE

This study aimed to compare long-term outcomes of open Burch colposuspension with the retropubic midurethral sling.

STUDY DESIGN

A matched cohort study of 1344 women with urodynamic stress incontinence (without intrinsic sphincter deficiency) who underwent surgery for stress urinary incontinence. Women had either open Burch colposuspension or the retropubic midurethral sling, from January 2000 to June 2018, in a tertiary center. Follow-up was by chart review and one-time phone follow-up until 2019, using a dedicated database. Primary outcomes were the presence or absence of stress urinary incontinence on follow-up, the success of index surgery based on response to validated questionnaires of patient-reported outcomes, and retreatment rates. Secondary outcomes are described below. Matching (1:3) was done at baseline to avoid confounding.

RESULTS

The study included 1344 women who had either Burch colposuspension (336) or retropubic midurethral sling (1008). Mean follow-up was 13.1 years for Burch colposuspension and 10.1 years for retropubic midurethral sling. In the Burch colposuspension group, 83.0% of patients (279 of 336) reported no ongoing stress urinary incontinence at the time of the latest follow-up vs 85.0% (857 of 1008) in the retropubic midurethral sling group (P=.38). Success in terms of the latest reported International Consultation on Incontinence Questionnaire-Urinary Incontinence Short Form (defined as International Consultation on Incontinence Questionnaire-Urinary Incontinence Short Form score of ≤6) where these data were available were similar within both groups: 76.0% (158 of 208 where this was available) in Burch colposuspension vs 72.1% (437 of 606 where this was available) in retropubic midurethral sling (P=.32). Where this information was available, success defined by a Patient Global Impression of Improvement of "very much improved" and "much improved" was similar between Burch colposuspension and retropubic midurethral sling groups (84.1% [243 of 289] vs 82.0% [651 of 794]; P=.88). Where data were available, 88.1% of women (178 of 202) in the Burch colposuspension group said they were very likely to recommend the surgery to family or a friend vs 85.0% (580 of 682) in retropubic midurethral sling (P=.30).Overall, 3.6% needed repeat incontinence procedures (13 in Burch colposuspension group [3.8%] vs 35 in retropubic midurethral sling group [3.5%]; P=.73). The incidence of mesh exposure was 1.0 %. Notably, 1 Burch colposuspension patient had a suture in the bladder during follow-up; 5 patients have reported long-standing pain across the study population. Overall, 51 women reported new-onset overactive bladder symptoms on follow-up: 10 of 336 (3.0%) had Burch colposuspension and 41 of 1008 (4.1%) had retropubic midurethral sling (P=.41). The need for future prolapse surgery per index procedure was 3.3% after Burch colposuspension vs 1.1% postretropubic midurethral sling (P=.01). Moreover, 9 of the 11 patients who needed a prolapse repair after Burch colposuspension required a posterior repair. The incidence of long-term severe voiding difficulty needing self-catheterization was similar in both groups (0.3% in Burch colposuspension and 0.5 % in retropubic midurethral sling group; P=1.00).

CONCLUSION

This study shows no difference in success, patient satisfaction, or complications between Burch colposuspension and retropubic midurethral sling, although the risk of posterior compartment prolapse operations after Burch colposuspension is increased. Reoperation rates for incontinence were similar in both groups. Chronic pain was a rare outcome.

Comparison of synthetic mesh erosion and chronic pain rates after surgery for pelvic organ prolapse and stress urinary incontinence: a systematic review

BACKGROUND

The aim of this study is to systematically compare rates of erosion and chronic pain after mesh insertion for pelvic organ prolapse (POP) and stress urinary incontinence (SUI) surgery.

METHODS

A systematic electronic search was performed on studies that evaluated the incidence of erosion and chronic pain after mesh insertion for POP or SUI. The primary outcome measurement was to compare mesh erosion rates for POP and SUI surgery. Secondary outcome measurements were incidence of de novo pain and a comparison of patient demographics for both surgeries.

RESULTS

Twenty-six studies on 292,606 patients (n = 9077 for POP surgery and n = 283,529 for SUI surgery) met the inclusion criteria. Median follow-up was 26.38 ± 22.17 months for POP surgery and 39.33 ± 27.68 months for SUI surgery. Overall, the POP group were older (p < 0.0001) and had a lower BMI (p < 0.0001). Mesh erosion rates were significantly greater in the POP group compared to the SUI group (4% versus 1.9%) (OR 2.13; 95% CI 1.91-2.37; p < 0.0001). The duration from surgery to onset of mesh erosion was 306.84 ± 183.98 days. There was no difference in erosion rates between abdominal and transvaginal mesh for POP. There was no difference in erosion rates between the transobturator and retropubic approach for SUI. The incidence of chronic pain was significantly greater in the POP group compared to the SUI group (6.7% versus 0.6%) (OR 11.02; 95% CI 8.15-14.9; p < 0.0001). The duration from surgery to onset of chronic pain was 325.88 ± 226.31 days.

CONCLUSIONS

The risk of mesh erosion and chronic pain is significantly higher after surgery for POP compared to SUI. These significant complications occur within the first year after surgery.

Delayed presentation of mons pubis abscess formation following MUS-case report and surgical video

INTRODUCTION AND HYPOTHESIS

Mid-urethral sling (MUS) surgery for stress urinary incontinence (SUI) has relatively low complication rates. However, although rare, complications such as bladder wall, prepubic and thigh abscess occur. We present an unusual case of MUS vaginal mesh exposure followed by mons pubis abscess formation occurring 18 years postoperatively because of inadvertent prepubic insertion of the right arm. Our objectives were to raise awareness about such a rare complication and to describe the approach for sling removal.

METHODS

A 75-year-old woman presented with gradual swelling on the mons pubis followed by pain with a past history of MUS insertion. Examination revealed a palpable, tender, non-fluctuant mass, extending about 10-15 cm from mons pubis to the right labia. There was a 2 × 2-cm vaginal mesh exposure. Following imaging, an examination under anaesthesia was performed with vaginal exploration and complete removal of the right arm of the MUS and closure of the vagina.

RESULTS

Six months postoperatively, all surgical sites had healed well, and there was no recurrent SUI or persistent mesh exposure.

CONCLUSIONS

Unusual long-term complications of MUS should be considered and recognized. Thorough evaluation is crucial for informed decision-making related to treatment strategies. The vaginal approach to mesh removal is safe and should be practised by experienced surgeons. Patients should be informed regarding the possibility of incontinence after sling removal.

What to do after a mid-urethral sling fails

PURPOSE OF REVIEW

After the Food and Drug Administration Public Health Notification in 2011 regarding transvaginal mesh, there has been a decline in the use of mid-urethral slings (MUS). However, they are an effective treatment option for stress urinary incontinence (SUI) with minimal complications. The management of recurrent SUI after sling continues to be debated.

RECENT FINDINGS

Long-term follow-up after primary MUS confirms its efficacy and safety. There remains no level 1 evidence for the best next step after a failed MUS. Preferred treatment strategies include placing a repeat MUS with more recent evidence demonstrating no difference in cure rates between transobturator tape and retropubic approach. Pubovaginal slings (PVS) and urethral bulking agents are also acceptable treatment options. A newer bulking agent, polyacrylamide hydrogel, demonstrated excellent short-term success rates in patients after a failed sling.

SUMMARY

MUS is an effective treatment option for SUI. Patients who develop recurrent urinary incontinence are a heterogeneous population who must be evaluated for detrusor overactivity, misplaced sling, unrecognized ISD. Patients with ISD are more likely to benefit by a PVS. Other patients with demonstrated recurrent SUI will likely do well with a repeat MUS.